Delay in Diagnosing Diabetic Ketoacidosis (DKA)

The Kovel Case

Pregnancy-induced diabetes is a condition that all obstetricians are trained to look for when treating their pregnant patients. As an example, it has become routine in America for all pregnant patients to have their urine checked for signs of diabetes at each and every prenatal visit. The reason for this is that undiagnosed diabetes can be fatal for either the mother or her baby. Diabetes treated appropriately with insulin will result in a normal pregnancy and delivery.

In June of 1997, Mother-Plaintiff was in her 29th week of pregnancy with her first child. She had been seen for her prenatal care at Magee Women’s Hospital. On June 23, at approximately 11:30 a.m., Plaintiff presented to Magee complaining of multiple episodes of nausea and vomiting (symptoms of gestational diabetes) for approximately three days, June 23 was the first day for new residents at Magee. The junior resident who admitted Plaintiff through the emergency room requested a copy of the prenatal chart, but the prenatal chart could not be found. Had that chart been located, the junior resident would have seen that Plaintiff had lost, rather than gained weight during her pregnancy (a sign of diabetes) and had not yet undergone an ordered glucola test to rule out diabetes. The junior resident diagnosed gastroenteritis (upset stomach) and dehydration, despite a urine test suggestive of diabetes.

Shortly after Plaintiff’s admission to Magee, a urinalysis indicated a value that Magee Hospital’s own guidelines characterize as a “panic value” for gestational diabetes; however, nobody read the urinalysis.

Plaintiff started labor contractions and was ordered to take Terbutaline by IV, a drug to stop preterm contractions. Per Magee Hospital’s protocols, a “stat” serum glucose test was ordered before the Terbutaline was started because Terbutaline is known to aggravate a diabetic condition. Contrary to Magee’s protocols, however, the Terbutaline was started before the result of the serum glucose test was read. The serum glucose test indicated that Plaintiff’s blood glucose was more than three times the normal level, diagnostic of diabetes. Unfortunately though, just like the previous urinalysis, the serum glucose test was never read until Plaintiff lapsed into a diabetic coma some 12 hours later. The residents who were attending to Plaintiff have acknowledged that they were remiss in not looking for the results of the serum glucose test. Compounding this omission on the residents’ part, a back-up computer system in place to convey dangerously high lab values from the lab to the physicians on the floor had not been properly maintained and did not function so as to inform the residents of Plaintiff’s dangerous serum glucose level. The Terbutaline was therefore permitted to infuse for 2 ½ hours, thereby aggravating Plaintiff’s undiagnosed Diabetic Ketoacidosis.
Tiffany lay in her hospital bed, exhibiting glaring signs of an impending diabetic coma; however, none of the residents attending to Plaintiff possessed the experience or knowledge to appreciate Plaintiff’s life- threatening condition. Instead, they believed she was merely experiencing anxiety. In the hours leading up to Plaintiff’s lapse into her diabetic coma, the residents responsible for Plaintiff’s care were consumed by other patients. On this evening, the Labor and Delivery suite at Magee had about twice as many patients as was typical during a busy shift; and there was no system in place for the residents to obtain any back up. There were no attending physicians available.

Even excluding her undiagnosed Diabetic Ketoacidosis, Plaitniff was certainly a high-risk, complex obstetrical patient: preterm labor contractions with unexplained complaints such as hyperventilation, disorientation, nausea and vomiting. Yet, no board certified doctor ever saw Plaintiff until about an hour and a half after she lapsed into her coma, some 18 hours after her admission to the hospital.

A woman in a coma should not undergo surgery. A C-section performed on a woman in a coma will likely kill the woman. As Plaintiff lay in a coma, her baby’s health deteriorated and a C-section was the only way the baby could be saved. For 22 hours, Plaintiff’s doctors helplessly watched her fetus’ compromising status, unable to perform the needed C-section, for fear of causing Plaintiff’s death.

Finally, Plaintiff stabilized somewhat and the C-section was performed. The baby was delivered and, predictably, was virtually lifeless at his birth. He was immediately taken to the neonatal intensive care unit, and his medical care since then has been intense. The baby has impairments and complications as a result of his Mother-Plaintiff’s metabolic acidosis and the lengthy period of time when he experienced fetal distress and could not be delivered.

The baby boy’s impairments are permanent. He has severe brain damage. He will never be able to walk. He will never be able to talk. He will never be able to be left alone. He has suffered severe/significant brain injury.